Editorial -- Health Homes: Keeping Clients Front and Center

From ACRIA and GMHC

Fall 2011

Today, people with HIV are living longer, but many
experience additional chronic conditions such as asthma,
diabetes, and cardiac problems. They also often need
housing, food assistance, substance use services, job training,
support groups, and treatment education. Since no single
agency can meet all of these needs, some people visit dozens
of organizations. As part of the Affordable Care Act, the health
care legislation passed in 2010, the U.S. Department of Health
and Human Services is promoting "coordinated care".

Coordinated care means collaboration among primary care
doctors, medical specialists, and nonmedical providers. The
National HIV/AIDS Strategy also endorses coordinated care
as a promising new direction. Ideally, it means taking all of a
person's needs into account instead
of just treatment for symptoms as
they arise. In order to be successful,
it must prioritize the client's own voice
in all health care decisions.

The rapid rise in U.S. health
care costs has resulted less from
higher quality care than from higher
profits and administrative costs.
Clients receive better care when they
develop a plan with a single provider
who anticipates long-term needs and
oversees the delivery of all services.
Better coordination can prevent
unnecessary duplication of services
and readmission to hospitals and
ERs, where care is costly and
rarely includes adequate follow-up.
Additionally, the coordinating provider
is better equipped to spot problems
early and intervene before they
become dangerous and expensive.

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This approach seems logical, but health care in this
country remains remarkably disorganized, and according
to a 2008 report in the New England Journal of Medicine,
little consultation occurs between providers, even in dire
situations. When a recently hospitalized client returns to
a primary care doctor, it is unlikely that doctor will have
received any information about the discharge plan. The
report also estimates that 33% of physicians do not
consistently notify their patients about abnormal test results.

Our health care system still functions on a profit-driven
model that prioritizes short-term payment over the long-term
well-being of patients. How are people supposed to manage
their care if no one sees the full picture of their health?

People with HIV who have other conditions are far more
likely to report undergoing unnecessary procedures and,
worse, having serious ailments overlooked. Faulty referrals
and incomplete background information make them more
likely to be unnecessarily hospitalized, which can raise costs,
stress, and stigma. These negative experiences, combined
with a feeling of alienation from uninformed providers, can
lead them to forgo care altogether. This lack of coordination
can perpetuate health disparities, leaving the most
vulnerable populations without adequate health support.

Many people with HIV manage their care and services
through COBRA, a case management program that connects
Medicaid clients with comprehensive services. But COBRA
is underfunded and does little to encourage communication
among providers. The Affordable Care Act gives states the
option of providing "Health Homes" services for Medicaid
enrollees, and they are encouraged to do so, with the federal
government covering 90% of the cost in the first two years.

According to guidelines released
by the Centers for Medicare
and Medicaid Services (CMS), a
designated Health Homes provider
will oversee all care, linking clients
to a team of specialists, nurses,
pharmacists, dieticians, social
workers, behavioral health providers,
chiropractors, and even alternative
medicine providers. The guidelines
include important factors like
transitional and culturally appropriate
care, aimed at maintaining people
with chronic conditions in care for
the long term.

So far, providers and clients alike
have been frustrated by the lack
of available information regarding
Health Homes, and many worry that
the transition into coordinated care
could disrupt current client-provider
relationships, particularly for those in
Medicaid-paid COBRA case management.

Care coordination is an essential step in the fight to end
AIDS, but only if clients have control. They must feel a sense
of ownership over their own health, and personally commit to
adhering to care. CMS has recommended that states treat
the "whole person" by incorporating the voice of clients, and
it is our responsibility as health care advocates to ensure
this. Coordinated care can save Medicaid dollars, but only if
quality health care remains the first priority.

Health Homes has potential for building trusting
relationships that will take precedence over profit. Its
success or failure depends on a collective effort to monitor
and critique the program. We must build alliances among
clients, providers, public and private insurers, health delivery
systems, and community and labor organizations. And we
must pay close attention to the implementation of the Health
Homes program to ensure that it adequately addresses health
disparities and bring new opportunities to people with HIV.

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